Using Sensei Cloud Oral Surgery
To document chief concerns:
Open the patient's record.
On the Patient tab, select Clinical > Clinical Chart (EMR).
On the right side of the window, click Define Chief Concerns. The Create Patient Chief Concern window is displayed.
In the Chief Concern field, select Facial Swelling.
In the Additional Details field, type Swelling accompanied by pain.
Click Create.
To record vital signs:
On the Patient tab, select Clinical > Clinical Chart (EMR).
On the right side of the window, select Add to Chart > Vitals. The Patient’s Vitals window is displayed.
Record the patient's blood pressure and pulse.
Select the site from which the blood pressure was measured.
Record the patient's height and weight. The BMI is calculated automatically.
Record the respiration rate and temperature.
Record the SpO2 percentage and ETCO2.
To create an anesthesia record:
On the right side of the Patient tab, select Manage Appointment > Anesthesia Record.
On the General Information tab of the Anesthesia Record, record information in the Patient Information, Record Overview, and Surgery Details sections.
Click Update Record.
To associate a procedure with a CPT code:
On the Administration tab, select Procedures & Fees > Procedure List & Fee Schedule. The Procedure List & Fee Schedule is displayed.
Select a code in the list. The Update Procedure window is displayed for the code.
Use the CPT Code field to search for the appropriate medical cross-code.
Make any necessary changes to the code.
Click Update.
Using the EMR Clinical Interface
Using Clinical Notes Templates
Recording the Pre-Op Evaluation